United States District Court, E.D. Missouri, Eastern Division
D. NOCE, UNITED STATES MAGISTRATE JUDGE
action is before the court for judicial review of the final
decision of the defendant Commissioner of Social Security
denying the application of plaintiff Michael Elder, Jr., for
supplemental security income benefits (SSI) under Title XVI
of the Social Security Act, 42 U.S.C. §§ 1381-1385.
The parties have consented to the exercise of plenary
authority by the undersigned United States Magistrate Judge
pursuant to 28 U.S.C. § 636(c). For the reasons set
forth below, the final decision of the Commissioner is
reversed and remanded for further consideration.
was born in 1968 and was 47 years old at the time of his
hearing. He filed his application on October 31, 2013,
alleging a September 21, 2000 onset date. (Tr. 153-58). In
his Disability Report, he alleged disability due to nerve
damage with pain in the left arm, left and right knee pain,
left hip pain, emotional problems, and major depression. (Tr.
at 210). His application was denied, and he requested a
hearing before an ALJ. (Tr. 1-6, 14-16, 98-102).
January 7, 2016, following a hearing, an ALJ found that
plaintiff was not disabled as defined in the Act. (Tr.
17-38). The Appeals Council denied his request for review.
(Tr. 1-3). Thus, the decision of the ALJ stands as the final
decision of the Commissioner.
has an extensive medical history. The court summarizes
plaintiff's medical records to the extent relevant to
21, 2013, plaintiff was treated in the emergency room after
being hit in the leg with an ax handle and was diagnosed with
a contusion. His left knee was placed in an immobilizer and
he was prescribed hydrocodone-acetaminophen. (Tr. at 236,
September 17, 2013, plaintiff was seen in the emergency room
with thoughts of killing his mother and step-father. He
reported increased thoughts of suicide over the previous
several weeks. Plaintiff reported symptoms of depression,
increased irritability, difficulty with concentration and
focus, and difficulty sleeping. His urine drug screen was
positive for marijuana and his blood alcohol level was 0.2.
Plaintiff improved with lithium. He was discharged with a
diagnosis of major depressive disorder, and prescribed
Celexa, an anti-depressant; trazodone, for insomnia; and
lithium, for mood stability. (Tr. at 261-63
was hospitalized at Phelps County Regional Medical Center
December 8-16, 2013 after overdosing on lithium and vodka. He
reported planning to cut his wrists. He was diagnosed with
depression, alcohol use disorder, marijuana use disorder,
personality disorder, not otherwise specified, and substance
abuse. His GAF score was “About 60.” Plaintiff
participated in group therapy and was much improved and
stable upon discharge. Because he did not have an income or
housing, he was discharged to a shelter to follow up at
Pathways Behavioral Health (Pathways). (Tr. at 275-79).
February 6, 2014, plaintiff underwent a psychological
examination by Thomas J. Spencer, Psy. D., to determine
Medicaid eligibility. He reported a history of nerve damage
in his left arm, as well as depression with symptoms of lack
of energy, isolating himself, difficulty sleeping, racing
thoughts, and inability to focus. He also reported abusing
alcohol. On exam, Dr. Spencer noted plaintiff had flat speech
and restricted affect. He diagnosed alcohol dependence in
early remission, bipolar disorder, and polysubstance
dependence in sustained remission. Dr. Spencer assessed a GAF
score of 50 to 55 and opined that plaintiff's mental
illness interfered with his ability to engage in employment.
(Tr. at 314-18).
7, 2014, plaintiff underwent another Medicaid evaluation. He
reported experiencing low back pain, left knee pain, and left
arm pain. Plaintiff reported that he had been involved in a
work accident in 2000, sustaining a cut to his arm and nerve
damage. He had also been attacked with an ax handle in 2013.
Upon exam, he had decreased range of motion of the left
shoulder, elbow, hand and wrist, as well as of the knees and
lumbar back. He was diagnosed with chronic back pain, left
knee pain, and permanent nerve damage to the left upper arm
secondary to laceration. The examiner found plaintiff had a
loss of normal function of the left hand as well as decreased
strength of the left arm. (Tr. at 330-33).
8, 2014, plaintiff began treatment at Pathways Behavioral
Health. On July 11, 2014, he saw Bhaskar Gowda, M.D., a
psychiatrist. Plaintiff reported his history of depression
and substance abuse. He said that he felt he had been doing
well until he injured his hand and became unable to work when
he started feeling depressed, hopeless, and helpless.
Plaintiff reported experiencing symptoms of constant worry,
edginess, and difficulty sleeping. Dr. Gowda diagnosed major
depressive disorder and assessed a GAF score of 50. He
started plaintiff on Seroquel, an antipsychotic medication.
(Tr. at 764-72).
August 1, 2014, plaintiff reported that he was no longer
drinking alcohol, although he continued to feel depressed and
hopeless. He also reported experiencing restlessness while on
Seroquel, and Dr. Gowda therefore decreased his dosage. (Tr.
at 754-55). Plaintiff continued to report symptoms of
anxiety, difficulty concentrating, anger, depression,